Almost everyone over the age of 60 should receive the zoster vaccine

Herpes zoster (or shingles) is caused by the same virus that causes chicken pox.

Zoster increases in incidence with advancing age. It is estimated that over 1 million Americans get shingles annually with the resulting acute discomfort and often chronic pain thereafter. A vaccine was introduced by Merck in 2006; the initial studies of 38,546 patients indicated that it reduced the incidence by about 50% and for those who still got shingles, the severity was lessened substantially. But acceptance of the vaccine has been slow. It seems that this is due to a combination of lack of knowledge that it is available and is effective; failure of physicians to inform their patients; and a fairly high cost of about $200, often not covered by insurance.

A study was reported in JAMA in January 2011. Kaiser Permanente, Southern California and Centers for Disease Control and Prevention investigators evaluated 75,761 Kaiser members who had no underlying immunological disorder and who had been vaccinated between January, 2007 and December 2009. These were compared to a control group of 227,283 age matched members who had not been vaccinated.

Among the unvaccinated individuals, this study showed that, as anticipated, shingles incidence goes up with age from – 60-64 years of age (9.7 infections per 1000 person years) to over age 80 (17.3 per 1000 person years).

Vaccination reduced the frequency by about 50% from a total of 13.0 per 1000 person years to 6.4 per 1000 person years. This halving of incidence was found at all age intervals, indicating that the vaccine works as well in the very elderly as in “younger” individuals. The incidence of zoster was steady over time. For example, at one year, slightly more that 1% of the unvaccinated individuals had developed zoster compared to less that 0.05% in the vaccinated group; at two years the numbers were about 2 ½ % and 1%, respectively. During the time of patient follow-up, this can be stated as one case of herpes zoster was prevented with each 71 vaccinated. However, since the follow up was only about 1 ½ years for most individuals and since it is estimated that beginning at age 60 a person has a 20% lifetime risk of zoster, it is my presumption that it actually takes many fewer individuals vaccinated to prevent one episode of zoster over the rest of one’s life.

Not part of this study, the original Merck investigation demonstrated that many older people do not respond well to the vaccine with increases in antibody production. This finding is consistent with many others that those over 60 years of age respond much less well than do those who are younger. This raises the question as to whether it would be useful to measure antibody production after vaccination to determine who has and who has not responded well. Perhaps those who do not should get a second vaccination. This is an important issue for all vaccines in older people. The same occurs with influenza vaccine which is why, this year, the dose for older people was doubled. But perhaps there are other approaches as well to improving the response rates for those at increased risk in their older years who respond less well to vaccines.

The study makes clear that this vaccine is effective, including for those over 80 years of age where the incidence is the highest. Given the implications of herpes zoster in immediate and longer term suffering and the attendant costs, I believe this is a vaccine that essentially everyone over the age of 60 (other than immunocompromised individuals) should receive. Insurance should pay for it just as with the influenza vaccine.

Even if paid for out of pocket, it is worth it. Patients need to ask for it and doctors need to encourage it.

Stephen C. Schimpff is a retired CEO of the University of Maryland Medical Center in Baltimore and is the author of The Future of Medicine — Megatrends in Healthcare. He blogs at Medical Megatrends and the Future of Medicine.

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  • niemand

    What is the difference between the Zoster vaccine and chickenpox vaccine we give to children?

    • http://www.medicalmegatrends.blogspot.com Stephen Schimpff MD

      It is fundamentally the same but formulated differently. Both chicken pox and herpes zoster are caused by the same virus – the varicella zoster virus. Over the years our immunity to the natural infection of childhood chickenpox wanes so the “shingles” vaccine is a good idea. Presumably when children who got the varicella vaccine reach “senior” status, they too will need the boost of the shingles vaccine.

      • niemand

        Well, that’s my point. Why not give the pediatric varicella vaccine to adults as the zoster vaccine? Intutively, it should work. There may be practical considerations I’m not aware of.

        Apart from FDA/regulatory problems. If that were not an issue. Is it the dose? Not enough virus antigen to stimulate an immune response in an older patient?

        As you mentioned, “formulated differently” in what way?

  • Muddy Waters

    Any financial conflicts of interest to declare?

  • solo fp

    I think they have approved the vaccine to age 50. I try to get all my 50-64 y.o. patients vaccinated. It is frustrating that the vaccine often is covered by Part D Medicare for a pharmacist to give to the patient, but Medicare part B for physicians does not cover the vaccine. Medicare wants pharmacists to give Zostavax over the patient’s regular physician.

  • MarylandMD

    On top of the Medicare hassles noted above, the sporadic shortages of vaccine do not help at all. We have had trouble keeping a steady stock, and have gone weeks (at one time months) without Zostavax. We really want to get the vaccine to our patients, but more than any other vaccine, logistical issues seem to be getting in the way.

  • http://www.medicalskeptic.com medskep

    Please check the following link: http://www.rxfiles.ca/rxfiles/uploads/documents/Zostavax-QandA.pdf

    Using those figures, the NNT(number needed to treat) for this vaccine is 59. That is 59 people need to receive the vaccine to prevent 1 case of shingles. Therefore the cost to prevent 1 case is $200 x 59 = $11,800. Is it reasonable to spend that amount of money to prevent a case?

    Also, according to the information at the link, the effectiveness of the vaccine decreases with age.

    Perhaps wide spread use of the vaccine is a good way to use health dollars but the case has yet to be explicitly made.

  • rich donahue

    cost out of pocket at a prominent boston hospital,$400.00. so far medicare will not cover.

    • pcp

      It’s covered under Part D, but any hospital charging $400 is running a racket.

      • ninguem

        pcp, you just described every hospital in the USA

        • pcp

          But when they become ACOs and control more of the market and own the docs and the rad centers and the labs, that will change, right?

  • walter keyes

    Was there subgroup analysis of patients who have already had herpes zoster?(did they statisticly benefit from the vaccine?)Also,you state those who developed hz after vaccine had milder cases.What factors were considered in evauluating severity and what were the specific statistics ra-elating to these factors?

    • pcp

      Anecdote: during the past year, I’ve had two patients, both in 60s, with full-blown zoster months after vaccination and subsequent post-herpetic neuralgia

  • Jo

    If I recall, early research of Zoster Vax showed numbers needed to treat were about 1100 to reduce one case, also if one contracted the virus and had received the vaccine the duration was only shortened by about 4 days. Maybe this is why it is not paid for???

    The vaccine does not significantly decrease risk and also does not significantly shorten duration, and numbers needed to treat are significantly high to reduce one case, therefore the vaccine does not justify cost, and worse yet gives false sense of security to patients that they will not get the virus.

    Better to educate patients that with first signs of painful rash, immediately go to their primary physician who should also be educated to treat agressively with antiviral with close follow up and another course of treatment if needed. If treated within the first week of appearance, this will “significantly” reduce the incidents of post-herpetic pain.

  • http://www.varicellavaccine.org/ Adile

    “The main purpose of any vaccine is not necessarily to entirely prevent the disease, but rather to prevent the serious or complicated form of the disease.” – Dr. Sears

    Adile

    • Jo

      (see former post) and…most importantly it does not significantly reduce the post herpetic pain if one gets the virus after vaccination if one does not quickly begin treatment with an antiviral. So according to Dr Sears’ and EBM the vaccine only prevents the “serious or complicated form of the disease” 1 out of 1100 vaccines.

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